Percutaneous arterial closure devices

Major femoral bleeding complications after percutaneous coronary intervention: incidence, predictors, and impact on long-term survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005

OBJECTIVES

The purpose of this study was to evaluate secular trends and factors associated with major femoral bleeding after percutaneous coronary intervention (PCI) in routine clinical practice during the past decade and to assess the impact of these complications on outcomes including mortality.

BACKGROUND

Significant changes in patient demographic data, adjunctive pharmacotherapy, and access site management have occurred during the coronary stent era. Trends in major vascular complications after PCI during this time have not been well characterized.

METHODS

Consecutive patients who underwent transfemoral PCI from 1994 to 2005 at the Mayo Clinic (n = 17,901) were studied. Patients were divided into 3 groups: Group 1 (1994 to 1995, n = 2,441); Group 2 (1996 to 1999, n = 6,207); and Group 3 (2000 to 2005, n = 9,253).

RESULTS

The incidence of major femoral bleeding complications decreased (from 8.4% to 5.3% to 3.5%; p < 0.001). Reductions in sheath size, intensity and duration of anticoagulation with heparin, and procedure time were observed (p < 0.001), and multivariate analysis confirmed each as an independent predictor of complications (p < 0.001). Adverse outcomes of major femoral bleeding included prolonged hospital stay (mean 4.5 vs. 2.7 days; p < 0.0001) and increased requirement for blood transfusion (39% vs. 4.7%; p < 0.0001). Major femoral bleeding and blood transfusion were both associated with decreased long-term survival, driven by a significant increase in 30-day mortality (p < 0.001 for both).

CONCLUSIONS

We noted a marked decline in the incidence of major femoral bleeding after PCI over the past decade. Mortality associated with these bleeding complications and with blood transfusion remains a significant issue.

A randomised controlled trial comparing StarClose and AngioSeal vascular closure devices in a district general hospital--the SCOAST study

AIMS

AngioSeal and StarClose are vascular closure devices (VCDs) that can be used following cardiac catheterisation via the femoral artery to achieve haemostasis. Both devices have been demonstrated to be superior to conventional manual pressure, which reduce time to haemostasis and time to patient ambulation. We sought to compare these devices in a prospective, randomised trial.

METHODS

Patients undergoing elective coronary angiography were randomised to receive either AngioSeal VIP or StarClose VCD with immediate postprocedure mobilisation. Bruising was recorded at 30 min, 60 min and at 1 week postprocedure. Patient satisfaction surveys were taken at 1 h and 1 week postprocedure. Complications for both groups were compared.

RESULTS

Four hundred and one patients were included. Arteriotomy closure was achieved in 144 of 208 (69.2%) patients randomised to AngioSeal and 134 of 193 (69.3%) patients randomised to StarClose (p = ns). There was no significant bruising in either group at either 30 or 60 min postprocedure. However, at 1 week, there was significantly more bruising in the AngioSeal group than the StarClose group (63.1 vs. 38.5cm2, p = 0.02). Patient satisfaction and pain perception with the procedure at closure were not significantly different between the groups. Deployment success and instant mobilisation rates were significantly lower for junior, as compared with senior, operators.

CONCLUSION

Achievement of haemostasis is similar with both AngioSeal and StarClose. The StarClose vascular closure device results in significantly less bruising at 1 week postprocedure as compared with AngioSeal, with no significant differences in complication rates. Patients' pain perception and satisfaction are similar with both VCDs.

Day-case diagnostic and interventional peripheral angiography: 10-year experience in a radiology specialist nurse-led unit

We describe a prospective evaluation of the safety of peripheral angiography procedures performed on day-case patients in a dedicated radiological nurse-led and administrated unit. Patients referred for peripheral vascular angiography, over a 10-year period, were pre-assessed by a radiology specialist nurse in a nurse-led clinic. Radiologists performed all procedures, whereas radiology specialist nurses were responsible for patient care before, during and after angiography and during the 24 h follow-up. Procedures were divided into diagnostic or interventional; complications were divided into immediate or delayed (24 h follow-up) either requiring hospital admission (major) or day-case unit management (minor). Patient acceptability was assessed using a standard questionnaire. Cost analysis was also performed. 401 day-case peripheral angiography procedures (144 diagnostic and 257 interventional) were performed in 310 patients. 109/401 (27.2%) procedures were performed on patients with diabetes mellitus. In diagnostic studies, 16/144 (11.1%) immediate and 6/144 (4.2%) delayed complications occurred whereas, in interventional studies, 65/257 (25.3%) immediate and 13/257 (5.1%) delayed complications were noted. A major complication occurred in 17/257 (6.6%) of patients in the interventional group and 3/144 (2.1%) in the diagnostic group. Puncture site haematoma was the most common complication. Nurse-led care was acceptable to the patient, with a high level of patient satisfaction seen. In conclusion, day-case diagnostic and interventional peripheral angiography procedures can be performed safely in a specialist nurse-led and administrated unit, with complication rates being within the accepted guidelines.

The clinical effectiveness of length of bed rest for patients recovering from trans-femoral diagnostic cardiac catheterisation

BACKGROUND

Cardiac catheterisation plays a vital role in the diagnosis and evaluation of cardiac conditions. The goal of management of patients after cardiac catheterisation is to reduce the risk of development of any local or prolonged vascular complications, in particular bleeding and haematoma formation at the puncture site. Bed rest and immobilisation of the affected leg are recommended practices to ensure adequate haemostasis at the femoral arterial puncture site and prevent complications.

OBJECTIVES

The objective of this review was to present the best available evidence for the optimal length of bed rest after trans-femoral diagnostic cardiac catheterisation. The main outcome of interest was the incidence of bleeding and haematoma formation following varying periods of bed rest.

SEARCH STRATEGY

We searched the following databases: CINAHL, Medline, Cochrane Library, Current Contents, EBSCO, Web of Science, Embase, British Nursing Index, Controlled clinical trials database, Google Scholar. Reference lists of relevant articles and conference proceedings were searched. We also contacted key organisations and researchers in the field.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials that compared the effects of different lengths of bed rest following trans-femoral diagnostic cardiac catheterisation on patient outcomes were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Odds ratios (OR) for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Eighteen trials involving a total of 4294 participants were included in the review. One trial included three treatment groups. In seven trials among 747 people there was no significant difference in the incidence of bleeding following six or less than 6 h of bed rest (OR 1.47; 95% CI 0.60, 3.64). Likewise, there was no significant difference in the incidence of bleeding following bed rest at other time periods. In eight trials involving 2272 patients there was no significant difference in the incidence of haematoma formation following 6 or less than 6 h of bed rest (OR 0.82; 95% CI 0.59, 1.16). Significantly fewer patients randomised to less than 6 h of bed rest complained of back pain. The odds of developing back pain at 4 (OR 24.60; 95% CI 1.29, 469) and 24 h (OR 2.47; 95% CI 1.16, 5.23) following coronary catheterisation was significantly higher among patients randomised to 6 compared with 3 h of bed rest.

AUTHORS' CONCLUSIONS

There is evidence of no benefit relating to bleeding and haematoma formation in patients who have more than 3 h of bed rest following trans-femoral diagnostic cardiac catheterisation. However, there is evidence of benefit relating to decreased incidence and severity of back pain and cost-effectiveness following 3 h of bed rest. There is suggestive but inconclusive evidence of a benefit from bed rest for 2 h following trans-femoral cardiac catheterisation. Clinicians should consider a balance between avoiding increased risk of haematoma formation following 2-2.5 h of bed rest and circumventing back pain following more than 4 h of bed rest.

Iatrogenic stenosis following suture-mediated closure device

The use of percutaneous closure devices post arterial punctures has been introduced to reduce time to haemostasis, reduce haemorrhage, improve patient comfort and reduce time to ambulation. Their increased use has been a result of larger access sites for more complicated procedures, periprocedural anticoagulation and concomitant use of anti-platelet therapy. Although complication rates are not increased with their use as compared with mechanical compression, complications may be more severe and are an important consideration in their use. We report two cases of iatrogenic stenoses secondary to suture-mediated closure device. The first managed with open surgical repair and the second with cutting balloon angioplasty.

The safety and efficacy of the Angio-Seal closure device in diagnostic and interventional neuroangiography setting: a single-center experience with 1,443 closures

INTRODUCTION

We evaluated the safety and efficacy of the Angio-Seal closure device used to close arterial puncture sites in patients who had undergone diagnostic cerebral angiography and neurointerventional procedures.

METHODS

A total of 1,443 Angio-Seal devices were placed in 1,099 patients in the Interventional Neuroradiology Unit between May 2005 and August 2006. Of these, 670 were interventional and 745 were diagnostic cerebral angiographic procedures. In 28 patients bilateral puncture of the femoral arteries was performed for endovascular treatment. In 167 patients 286 repeat diagnostic procedures were performed and 30 interventional procedures were followed by re-closure with an Angio-Seal device at the time of repeat puncture.

RESULTS

The procedural success rate for antegrade closures was 99.7% for all procedures. The device failed in 5 of 745 diagnostic procedures (0.7%). Major complication occurred in one patient only (0.13%) in the diagnostic group. No minor complications were observed in this group. In the interventional group, the major complication rate was 1.4% (10 of 698 closures) and the minor complication rate was 2.4% (17 of 698 closures). However, in the subgroup of patients with cerebral aneurysms who received heparin in combination with antiplatelet agents after the procedure, the major complication rate was 5.3%, but in the carotid/vertebral stenting group it was 0.8%.

CONCLUSION

Our experience in a relatively large series of patients shows that the use of the Angio-Seal STS vascular closure device is safe and effective in patients undergoing cerebral diagnostic angiography and neurointerventional procedures with an acceptable rate of complications, although the complication rate was higher in the group of patients who received heparin and/or antiplatelet medication.

StarClose Vascular Closure Device: Prospective Study on 222 Deployments in an Interventional Radiology Practice

The StarClose device (Abbott Vascular Devices; Abbott Laboratories, Redwood City, CA) utilizes an externally placed Nitinol clip to achieve arterial closure following femoral artery puncture. The objectives of this study were to assess the efficacy and complications of the StarClose device in patients undergoing interventional radiological procedures. Preprocedural clotting status, pulse and blood pressure, severity of vessel calcification, sheath size, and time to deployment were recorded. Postdeployment complications immediately postprocedure, at 1 h, at 2 h, and at 1 week were recorded. A duplex scan was performed in the first 10 patients to assess any immediate vascular complications. Deployments were successful in 96% achieving immediate hemostasis. Mean deployment time was 48 s. There were no major complications. The StarClose device was found to have a high technical and clinical efficacy.

A randomised controlled trial comparing the routine use of an Angio-Seal STS device strategy with conventional femoral haemostasis methods in a district general hospital

Femoral artery closure devices reduce the time to haemostasis and ambulation. Most district general hospitals (DGHs) now perform day case angiography on site. The purpose of this study was to assess the Angio-Seal self-tightening suture (STS) device in comparison with manual compression in this environment. A prospective randomised controlled trial was undertaken comparing the Angio-Seal STS device with manual pressure recording complications, time from end of procedure and patient satisfaction in a DGH setting. Angiography lists of 206 patients undergoing day case diagnostic cardiac catheterisation with a five French sheath at a DGH were randomised by intention to treat to receive either manual compression or a six French Angio-Seal STS device. Time from sheath removal to mobilisation, complication rate and patient satisfaction were compared. There were no significant differences between the two groups in terms of demographics (manual compression: Angio-Seal; male (%) 58 vs. 57, age (years) 65.4 vs. 66.3, body mass index (kg/m(2)) 27.7 vs. 27.5). Despite randomisation, only 74 of 107 patients in the Angio-Seal group actually had a device deployed. Angio-Seal use was associated with significantly shorter times to mobilisation (87.6 vs. 144.1 min; p < 0.001), significantly less bruising (bruise size at 1 week (28.5 vs. 82.5 cm(3); p < 0.01) and no increase in vascular complications. In addition, patients were more satisfied with Angio-Seal devices in terms of length of immobility. The routine use of Angio-Seal closure devices result in earlier mobilisation, less bruising, increased patient satisfaction with no increase in other complications in comparison to manual pressure.

The Endovascular Approach to Acute Aortic Trauma

Endovascular repair of the traumatically injured thoracic aorta has emerged as an exceptionally promising modality that is typically quicker than open repair, with a reduced risk of paralysis. There are a specific set of anatomic criteria that need to be applied, which can be rapidly assessed by the CT angiogram. The enthusiasm for endovascular repair must be tempered by recognition of the complications and lack of long-term follow-up, particularly in younger patients. Surgeons who are skilled in open aortic repair must not only be involved, but should take on a leadership role during the planning, deployment, and follow-up of these patients. Familiarity with all of the available devices expands treatment options. As more specific devices become available, and more follow-up is accrued, the role of endovascular stents will continue to grow.

Outpatient angioplasty and stenting facilitated by percutaneous arterial suture closure devices

AIM

To review our practice of outpatient percutaneous vascular interventions facilitated by an arterial suture device.

MATERIALS AND METHODS

A retrospective review of all patients attending this tertiary centre for iliac or femoral intervention was undertaken between February 2001 and December 2004. All patients who underwent angioplasty or stenting had their puncture sites closed using a Perclose suture. Patients were kept flat for 15min and allowed to fully mobilize at 60min. Puncture sites were scored for visible bruising, haematoma and pain at discharge and on outpatient follow-up. Patient preference for future outpatient treatment was assessed.

RESULTS

Fifty-seven outpatients underwent 81 punctures. Forty-eight (84%) patients underwent iliac angioplasty; of those 42% underwent stent placement. Six patients (10%) required inpatient admission, five secondary to failed suture deployment. One patient had a non-closer-related puncture site intimal flap occlusion successfully repaired at surgery. Fifty-one (90%) patients discharged with a mean time of 157min (60-280min). Forty-six (92%) patients had no visible bruising or palpable haematoma on discharge. No patient had a haematoma greater than 2.5cm. No discharged patient required readmission. Thirty percent reported a moderate to severe groin pain score (2-5/5) at discharge, increasing to 40% at follow-up. Forty-seven (98%) of the 48 patients, who expressed a preference, would be happy to undergo outpatient treatment again.

CONCLUSION

Outpatient treatment is feasible, well tolerated and preferable to patients, but 10% will require inpatient admission. A planned post-procedure analgesia regimen or advice should be considered.

Prospective Nonrandomized Trial of Manual Compression and Angio-Seal and Starclose Arterial Closure Devices in Common Femoral Punctures

We compared the use of manual compression and Angio-Seal and Starclose arterial closure devices to achieve hemostasis following common femoral artery (CFA) punctures in order to evaluate safety and efficacy. A prospective nonrandomized, single-center study was carried out on all patients undergoing CFA punctures over 1 year. Hemostasis was achieved using manual compression in 108 cases, Angio-Seal in 167 cases, and Starclose in 151 cases. Device-failure rates were low and not significantly different in the two groups (manual compression and closure devices; p = 0.8). There were significantly more Starclose (11.9%) patients compared to Angio-Seal (2.4%), with successful initial deployment subsequently requiring additional manual compression to achieve hemostasis (p < 0.0001). A significant number of very thin patients failed to achieve hemostasis (p = 0.014). Major complications were seen in 2.9% of Angio-Seal, 1.9% of Starclose, and 3.7% of manual compression patients, with no significant difference demonstrated; 4.7% of the major complications were seen in female patients compared to 1.3% in males (p = 0.0415). All three methods showed comparable safety and efficacy. Very thin patients are more likely to have failed hemostasis with the Starclose device, although this did not translate into an increased complication rate. There is a significant increased risk of major puncture-site complications in women with peripheral vascular disease.

Initial experience with the cardiva Boomerang™ vascular closure device in diagnostic catheterization

OBJECTIVES

The authors studied the safety and efficacy of the Cardiva Boomerang vascular closure device in patients undergoing diagnostic cardiac catheterization.

BACKGROUND

Conventional vascular closure devices (sutures, collagen plugs, or metal clips) have been associated with catastrophic complications including arterial occlusion and foreign body infections; furthermore, they cannot be utilized in patients with peripheral vascular disease or vascular access site in a vessel other than the common femoral artery. The Cardiva Boomerang device facilitates vascular hemostasis without leaving any foreign body behind at the access site, can be used in peripheral vascular disease, and can be used in vessels other than the common femoral artery

METHODS

A total of 96 patients undergoing transfemoral diagnostic cardiac catheterization were included in this study, including 25 (26%) patients with contraindications to conventional closure devices. Femoral angiography was performed prior to deployment of the Cardiva Boomerang closure device. Patients were ambulated at 1 hr after hemostasis was achieved.

RESULTS

The device was successfully deployed and hemostasis achieved with the device alone in 95 (99%) patients. The device failed to deploy in 1 (1%) patient and required conversion to standard manual compression. Minor complications were observed in 5 (5%) patients. No patients experienced major complications including femoral hematoma > 4 cm, red blood cell transfusion, retroperitoneal bleed, arteriovenous fistula, pseudoaneurysm, infection, arterial occlusion, or vascular surgery.

CONCLUSIONS

The Cardiva Boomerang device is safe and effective in patients undergoing diagnostic cardiac catheterization using the transfemoral approach, facilitating early ambulation with low rates of vascular complications.

Randomized controlled trial of topical hemostasis pad use for achieving vascular hemostasis following percutaneous coronary intervention

OBJECTIVES

We conducted a randomized trial to determine the efficacy of two topical hemostasis pads in promoting vascular hemostasis following PCI, and to assess the appropriate level of anticoagulation for sheath removal.

BACKGROUND

Pads coated with procoagulant materials are widely marketed and used to augment vascular hemostasis following PCI, yet clinical effectiveness and safety data are lacking.

METHODS

184 patients who underwent PCI using the femoral approach were randomized to one of four methods of sheath removal: (1) at ACT < 250 using the Chito-Seal pad; (2) at ACT < 250 using the Clo-Sur PAD; (3) at ACT < 250 using manual compression alone; (4) at ACT < 170 using manual compression alone.

RESULTS

Time to hemostasis was significantly shorter in the hemostasis pad groups compared to the conventional compression groups (16.2 +/- 4.9, 16.0 +/- 5.3, 19.3 +/- 7.8, and 18.3 +/- 5.7 min, respectively, P = 0.027), however overall bed rest times following intervention were not reduced by use of either hemostasis pad. The incidence of major or minor bleeding complications did not differ among groups. Irrespective of hemostasis pad use, removal of sheaths at higher ACT levels allowed shorter time to ambulation following PCI without an increase in bleeding events.

CONCLUSIONS

The hemostasis pads tested shortened time to hemostasis compared to standard manual compression, although the absolute reduction in time to hemostasis was relatively small and did not translate into a reduction in overall bed rest time. Independent of hemostasis pad use, removal of arterial sheaths at higher than conventional activated clotting times was safe and resulted in significant reductions in time to ambulation.

Ambulation 1 hour after diagnostic cardiac catheterization: a prospective study of 1009 procedures

OBJECTIVE

To study the safety of a protocol that allows ambulation 1 hour after diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system.

PATIENTS AND METHODS

A total of 1005 consecutive patients (1009 procedures) undergoing outpatient diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system at the Mayo Clinic in Rochester, Minn, were included in this study from January 1, 2004, to August 31, 2005. All patients underwent standard manual compression to achieve hemostasis and were ambulated after 1 hour of bed rest.

RESULTS

The mean age of the patients was 64.5 years, and 62% were male. Minor vascular complications occurred in 33 procedures (3.3%), Including 14 hematomas (1.4%) less than 4 cm and 19 cases of rebleeding (1.9%) that required repeated manual compression. Only 1 patient (0.1%) had a hematoma greater than 4 cm. No patient had a major complication, such as surgical repair, red blood cell transfusion, retroperitoneal bleeding, formation of an arteriovenous fistula or pseudoaneurysm, arterial occlusion, or an infection.

CONCLUSIONS

Ambulation 1 hour after diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system is safe and associated with low rates of vascular complications. This strategy may improve patient comfort, reduce resource utilization, and be preferable to use of vascular closure devices.

Stent-Grafts in the Management of Hemorrhagic Complications Related to Hemostatic Closure Devices: Report of Two Cases

We report 2 cases of hemorrhagic complications related to use of the Angio-Seal hemostatic closure device that were successfully managed with stent-grafts. Two patients with subarachnoid hemorrhage were referred to our departments for endovascular treatment of ruptured intracranial aneurysms. The treatment was performed through a femoral access; the sheaths were removed immediately after the procedures, and the punctures sites closed by Angio-Seals. Both patients presented clinical signs of hypovolemic shock after treatment. The diagnosis of active bleeding through the puncture site was made by emergency digital subtraction angiography. The lesions were managed with stent-grafts. The use of stent-grafts proved to be efficient in the management of these life-threatening hemorrhagic complications following the use of the Angio-Seal hemostatic closure device.

Postinterventional percutaneous closure of femoral artery access sites using the Clo-Sur PAD device: initial findings

The purpose of this study was to evaluate a percutaneous hemostatic device in patients to achieve immediate hemostasis at the vascular access site as well as early ambulation after vascular interventional procedures. In a randomized trial, a hemostatic device (Clo-Sur PAD, Medtronic AVE, Inc., Santa Rosa, CA, USA; n=60) was compared with manual compression (n=60) in patients after endoluminal intervention through an inguinal access (sheath sizes: 5-7 French). Device safety was evaluated by assessing complications within 24 h and 14 days. System efficacy was measured by the percentage of achieved immediate hemostasis and early ambulation. Device application was possible in 57 cases (95.0%), with 93.3% (56/60) of the patients rising 2 h after application. Hemostasis time was 10.15+/-1.96 min (control group: 16.20+/-1.79 min), with a pressure bandage time of 3.47+/-5.53 h (control group: 13.8+/-4.32 h). Ambulation was possible after 2.13+/-0.50 h (control group: 8.57+/-3.47 h). Complications encountered were access-site bleeding with hematoma (device: n=3; control: n=9). All complications were managed conventionally without blood transfusion or surgical intervention. The system is an easy to use device permitting early ambulation without additional pressure bandaging in the majority of patients. Preliminary data show that hemostasis does not depend on the level of anticoagulation.

Safety and efficacy of staple-mediated femoral arteriotomy closure: Results from a randomized multicenter study

BACKGROUND

Mechanical closure of percutaneous femoral arteriotomies following catheter based procedures remains problematic.

METHODS

The EVS closure device is the first to utilize a staple to effect arteriotomy closure and was compared to manual compression following sheath removal in a 362 patient randomized (2:1 to device) multicenter trial. As pre-specified, one half of the patients underwent coronary intervention.

RESULTS

Time to hemostasis was significantly reduced in the EVS group for both diagnostic (3.3 +/- 2.6 vs. 19.3 +/- 5.7 minutes; p < 0.001) and interventional procedures (5.5 +/- 5.1 vs. 22.3 +/- 9.9 minutes; p < 0.0001). Time to ambulation was similarly reduced in the EVS group following diagnostic (2.4 +/- 3.3 vs. 6.0 +/- 5.2 hours; p < 0.001) and interventional procedures (3.4 +/- 4.5 vs. 7.6 +/- 7.0 hours; p < 0.001). The incidence of major complications was similar between the EVS and manual compression groups at discharge (0.4% vs. 1.7%; p = NS) and at 30 day follow-up (0.4% vs. 2.5%; p = NS).

CONCLUSION

Compared to manual compression, the EVS device provides a safe and effective method of femoral artery closure.

Infectious complications of percutaneous vascular closure devices

OBJECTIVE

To describe the infectious complications of percutaneous vascular closure devices (PVCDs) on the basis of our institutional experience with PVCDs and the published medical literature.

PATIENTS AND METHODS

We retrospectively reviewed all cases of PVCD-related Infection seen at the Mayo Clinic in Rochester, Minn, between January 1, 2000, and December 31, 2003, and searched the English language medical literature for all previously published reports.

RESULTS

We identified 46 cases in the medical literature and 6 cases from our Institutional database. The median age of patients was 63 years (range, 40-79 years). Diabetes mellitus and obesity were the most common comorbidities. The median Incubation period from device Insertion to presentation with access-site infection was 8 days (range, 2-29 days). The most common presenting symptoms were pain, erythema, fever, swelling, and purulent drainage at the access site. Mycotic pseudoaneurysm (22 cases) was the most common complication. Staphylococcus aureus was responsible for most (75%) of the Infections. All patients underwent surgical debridement, and 54% required reconstructive procedures. The median duration of antibiotic treatment was 28 days (range, 7-42 days). The mortality rate was 6% (3 patients).

CONCLUSIONS

Infection associated with PVCD placement is uncommon but is an extremely serious complication. Morbidity is high, and aggressive medical and surgical interventions are required to achieve cure.

Case-controlled comparison of a percutaneous collagen arteriotomy closure device versus manual compression after liver chemoembolization

PURPOSE

To compare complications and outcomes between the use of the Duett collagen closure device after one or multiple deployments and manual compression in patients treated with transcatheter arterial chemoembolization (TACE) for primary or metastatic liver cancer.

MATERIALS AND METHODS

A database of 214 patients who underwent a total of 426 TACE procedures between July 2001 and July 2003 was retrospectively analyzed with regard to the use of the Duett closure device to obtain hemostasis. The Duett device was used in 211 cases (121 patients), whereas manual compression was performed in 215 cases (93 patients). Primary endpoints included complications related to hemostasis, time to hemostasis (TTH), time to ambulation (TTA), and time to discharge (TTD). Risk factors were tested for correlation with complications (P < .05). Other endpoints included descriptive data regarding the Duett treatment group.

RESULTS

Only minor complications were observed in both groups, without a statistically significant difference (P = .16). The mean TTH and TTA were significantly shorter (P < .0001) in the Duett group, whereas there was no difference in TTD between groups (P = .59). Reaccessing the same arterial site for separate procedures was not a significant risk factor for complications in the Duett group (P < .0001).

CONCLUSION

The Duett closure device achieves similar safety and efficacy as manual compression in this distinct group of patients. In addition, this device can be safely and repetitively deployed at the arteriotomy site after each TACE procedure.

The Safety and Efficacy of a Percutaneous Closure Device in Patients Undergoing Uterine Artery Embolization

PURPOSE

The use of suture-mediated closure devices (SMCDs) in patients undergoing uterine artery embolization (UAE) for symptomatic leiomyomata is controversial. With recent literature suggesting a higher complication rate with the use of SMCDs, their use in this specific population has been questioned. The purpose of this study is to assess the safety and efficacy of SMCDs specifically for those patients undergoing UAE for symptomatic uterine leiomyomata.

MATERIALS AND METHODS

A prospective database was established in a single high-volume medical center for patients undergoing UAE for symptomatic leiomyomata. Data were tracked prospectively, with technical outcome and complication rates serving as endpoints.

RESULTS

UAE was performed in 342 consecutive patients from January 2001 to September 2003. The SMCD was used in 328 of these patients (96%). Successful primary hemostasis was achieved in 320 of 328 patients (97%), with additional manual compression required in the remaining eight patients (3%). No major complications were observed. Minor complications consisted of minor hematomas in four women (1%) and anteriomedial thigh pain in 68 women (21%) within 1 month of follow-up, resulting in an overall complication rate of 22%. All symptoms related to anteromedial thigh pain ipsilateral to the arterial puncture site were managed conservatively with 1 week of oral nonsteroidal antiinflammatory medication.

CONCLUSION

The SMCD provided safe and effective hemostasis in patients undergoing UAE. Transient thigh discomfort, which may result from irritation of the anterior femoral cutaneous nerves (femoral neuralgia syndrome), was uniformly relieved with nonsteroidal antiinflammatory therapy.

[Treatment of postcatheterization femoral false aneurysms]

The incidence of iatrogenic femoral false aneurysms has risen dramatically in recent years and is estimated at 0,5% for diagnostic procedures and may rise to 9% or more for therapeutic procedures. This increased incidence is related to the increased number of arterial punctures performed for diagnostic or therapeutic purposes and their major complexity and duration. Risk factors for the development of iatrogenic false aneurysms include operator inexperience, age greater than 60, female gender, catheter size greater than 8F and concurrent anticoagulation. Prevention of false aneurysms is based upon an atraumatic arterial puncture, good compression therapy after sheath removal and use of percutaneous arterial closure devices. Contrarily to the arterial lesions following severe injuries, the natural course of false aneurysms is quite benign with spontaneous occlusion in the majority of cases. Therefore, a mandatory surgical approach is no longer advocated and alternative therapeutic options have been proposed. These include sonographic surveillance, compression ultrasonography, percutaneous thrombin or coil embolization. Surgery is still clearly indicated in presence of local nervous or venous compression, associated homolateral lower limb ischemia, great size of the aneurysm, and unsuccessful non-invasive treatment. Sonographic surveillance has shown to be safe in hospitalized or ambulatory patients. However, fear of aneurysm rupture and cost of repeated ultrasonographic exams preclude widespread utilisation. Compression ultrasonography is safe and effectiveness varies between 70 and 100%, according to studies. Compression ultrasonography may be painful, has often to be associated with mild analgesia, is time consuming and less effective in presence of concurrent anticoagulation. Thrombin injection seems particularly effective, is painless and has a limited rate of complications in expert hands. Severe anaphylactic reactions and severe coagulopathy in reexposed patients have been described and represent clear contra-indications to thrombin injection. Coil embolization of the false aneurysm is as effective as thrombin injection and is reported in a limited number of patients. There is no formal consensus about treatment of the vast majority of non-surgical false aneurysms. In an absence of stringent indication to surgical approach, compression ultrasonography may be used first as it is widely available, and does not require highly specialized skills. Compression therapy should be done after a transient interruption of anticoagulant treatment, if allowed by clinical context. If compression therapy fails, percutaneous injection of thrombin or coil embolization are effective and associated with a low complication rate. However, these techniques are less widely available and necessitate an experienced operator. As recurrences have been described with each of these techniques, every non-surgically-treated false aneurysm should be monitored for 24 hour with ultrasonography control to ensure effective thrombosis.

Granuloma Formation around a Retained Perclose S Suture Presenting 12 Months after Implantation

Suture-mediated closure devices have become commonplace in interventional and diagnostic femoral catheterization procedures. Although they reduce the time to hemostasis, ambulation, and hospital discharge, they are associated with a greater potential for serious infection compared with manual compression, often with delayed presentation. Scrupulous aseptic procedure and careful technique are vital in reducing complications. Herein a case of sterile granuloma formation around an untrimmed Perclose S suture is reported, which presented 12 months after use of a suture-mediated closure device.